Provider Demographics
NPI:1760933949
Name:HOGAN, BRENDA
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:
Last Name:HOGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 ISLAND WAY
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33767-1843
Mailing Address - Country:US
Mailing Address - Phone:414-477-7196
Mailing Address - Fax:
Practice Address - Street 1:770 ISLAND WAY
Practice Address - Street 2:
Practice Address - City:CLEARWATER BEACH
Practice Address - State:FL
Practice Address - Zip Code:33767-1843
Practice Address - Country:US
Practice Address - Phone:414-477-7196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2016-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WIH2500768460107172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker